Cardiovascular manifestations of systemic lupus erythematosus

Coronary artery bypass grafting in patients with systemic lupus erythematosus

OBJECTIVE

Few reports exist on the results of coronary artery bypass grafting (CABG) in patients with systemic lupus erythematosus (SLE).

METHODS

We retrospectively reviewed eight CABG in seven SLE patients. In early and late postoperative angiography, all grafts were evaluated for occlusion, development of string sign, or presence of significant stenosis. The early and late results were compared. The pathological studies were performed on the segments of the internal thoracic artery (ITA) and saphenous vein collected from each patient. Atherosclerosis of the ITA was analyzed using the subjective evaluation proposed by Kay et al. (Kay HR, Korns ME, Flemma RJ, Tector AJ, Lepley D. Atherosclerosis of the internal mammary artery. Ann Thorac Surg 21;1976:504-507) scale 0-4 (0 = normal, 1 = minimal disease, 2 = less than 25% luminal narrowing, 3 = 25-50% narrowing, and 4 = greater than 50% narrowing).

RESULTS

The patients consisted of three men and four women with a mean age of 59.8 years. Co-morbid diseases were frequent and there were three patients (37.5%) with renal failure (two dialysis patients, one with renal dysfunction) and two patients with severe atherosclerosis of the aorta. The ITA was used in four patients. Saphenous vein graft was used in seven patients. Concomitant procedures included aortic valve replacement and mitral annuloplasty, mitral valvuloplasty and tricuspid annuloplasty, mitral valve replacement and tricuspid annuloplasty (TAP). There was one hospital death (12.5%). Early patency rates were 87.5% (21/24). No other atherosclerotic changes or stenosis suggesting vasculitis were noted. In pathological studies, there was no significant atherosclerosis in the six ITA specimens from four patients, although three patients had degree two atherosclerosis. No vasculitis was found in ITA or saphenous vein grafts. During the mean follow-up period of 35.3 months (range, 5-91 months), there was one non-cardiac late death. Late restudy (in three patients, 12, 57 and 64 months later respectively) revealed no deterioration in either ITA or vein grafts. Overall prognosis after the operation in SLE patients appears to be good. No other cardiac events were observed, and patients demonstrated marked clinical improvement.

CONCLUSIONS

CABG in SLE patients can be performed with acceptable morbidity and mortality. Our data so far reveals no evidence to preclude the use of ITA and vein grafts in SLE patients.

Cardiac involvement in systemic lupus erythematosus

Systemic lupus erythematosus (SLE), a connective tissue disease characterized by the production of autoantibodies, can affect all organ systems. Cardiac involvement in patients with SLE has been described since the early 20th century. The manifestations are numerous and can involve all components of the heart, including the pericardium, conduction system, myocardium, valves, and coronary arteries. In recent years, echocardiography has yielded additional information about the heart in patients who have SLE with and without clinical cardiac involvement. Moreover, antiphospholipid antibodies have been linked to several cardiac manifestations in patients with SLE, including valvular abnormalities and possibly coronary artery disease. This updated, comprehensive review summarizes the new literature on SLE and the heart.

Prevalence of infective endocarditis in patients with systemic lupus erythematosus

BACKGROUND

Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions. These lesions may place patients with SLE at risk of developing infective endocarditis, or IE.

METHODS

The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE. They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE.

RESULTS

Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed. Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made.

CONCLUSIONS

The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance. Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures. However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE.

CLINICAL IMPLICATIONS

Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown. Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.

Myocardial infarction in patients with systemic lupus erythematosus with normal findings from coronary arteriography and without coronary vasculitis--case reports

The authors present the cases of two young patients, a man and a woman, who presented with myocardial infarction, in the absence of ischemic heart disease or stenosis of the coronary arteries. The woman was known to have systemic lupus erythematosus (SLE) for the past 3 years (the immunoglobulin M [IgM] anticardiolipins antibodies were positive), without a history of coronary risk factors. Suddenly she presented with acute chest pain on rest that lasted 4 hours and culminated in anterior wall myocardial infarction. She was admitted to the coronary care unit, where no thrombolysis was given. She did not have echocardiographic evidence of Libman-Sacks endocarditis, but myocardial infarction was evident at the electrocardiogram (ECG). The young man had SLE (the IgM anticardiolipins were absent, but he was positive for lupus anticoagulant antibodies), he was hyperlipidemic, was a moderate smoker and moderately obese, and had no history of ischemic heart disease. He suddenly presented with an acute myocardial infarction documented by ECG, enzymes, and gammagraphy. In both patients, coronary angiography findings were normal and myocardial biopsy did not show evidence of arteritis. The relevance of these cases is the rare association of ischemic heart disease in SLE, with normal coronary arteries and without evidence of arteritis or verrucous endocarditis.

Autoimmune rheumatic diseases and the heart

Involvement of the heart is a common finding in autoimmune rheumatic diseases. Although clinically silent changes are common, potentially life-threatening manifestations are well known but early recognition is important if appropriate therapy is to be instituted.

Lupus carditis: evaluation with technetium-99m MIBI myocardial SPECT and heart rate variability

The objective of this paper was to investigate the incidence of myocardial perfusion defects in patients with systemic lupus erythematosus (SLE) associated with dysautonomic alterations. Twenty patients without any sign or symptoms of heart disease, selected from a larger population of patients with SLE, underwent technetium-99m sestamibi (Tc-99m MIBI) single photon emission computed tomography (SPECT), at rest and after dipyridamole infusion; they also underwent heart rate variability (HRV) examination by a 24 hour ambulatory electrocardiography, analyzing in the time domain the standard deviation of the R-R intervals average (SDNN) and the percentage of R-R adjacent intervals differing from each other more than 50 msec (pNN50); in the frequency domain the low (LF) and high frequencies (HF) were analyzed. Twenty healthy volunteers served as control group for heart rate variability. At MIBI-SPECT examination, the scan was found abnormal in 15 patients and normal in five: three patients demonstrated reversible defects in the anteroseptal region, four had irreversible defects in a region (two in the anteroseptal region and two in the lateral region), two had rest defects in two different regions (lateral and inferior, lateral and anteroseptal) that improved during dipyridamole scan, and six had both reversible and irreversible defects: four in a single segment (three anteroseptal and one lateral, and two in two different regions, particularly anteroseptal and lateral, lateral and inferior). All 20 patients showed significantly lower HRV parameters in comparison with the control group, except for pNN50, which indicates decreased physiologic periodic fluctuations of the autonomic nervous system. In six patients who underwent coronary angiography, the epicardial vessels were found completely normal. In view of the high incidence of myocardial hypoperfusion in patients with HRV alterations, the authors hypothesize that autonomic dysfunction may be associated with microvascular disease or metabolic alteration. They also believe that MIBI scintigraphy is a suitable technique in detecting myocardial damage in SLE patients free of clinical manifestation.

111Indium antimyosin antibody imaging of primary myocardial involvement in systemic diseases

OBJECTIVE

The diagnosis of primary myocardial involvement in systemic diseases is clinically relevant but difficult in the absence of specific criteria. Whatever the underlying disease, myocytes degeneration is observed during the active phase of myocardial damage. The aim of this study was to assess the diagnostic value of scintigraphic imaging with 111Indium antimyosin antibody (AM), a specific marker of the damaged myocyte, for ongoing myocardial damage related to systemic diseases.

METHODS

40 patients with histologically confirmed systemic diseases were studied. They were classified into two groups according to the presence (group 1, n = 30), or the absence (group 2, n = 10) of clinical, electrocardiographic (ECG) or echocardiographic signs suggestive of myocardial involvement. Planar and tomographic acquisitions were obtained 48 hours after injection of AM (90 MBq). Rest 201thallium (T1) scintigraphy was also performed to assess myocardial perfusion and scarring. Clinical, ECG, and echocardiographic +/- scintigraphic evaluations were repeated during follow up (17 +/- 19 months) in 36 of 40 patients.

RESULTS

In group 1, 13 of 30 patients (43%) showed diffuse significant AM uptake throughout the left ventricle (LV), and no or mild T1 abnormality. Two of these were asymptomatic, four had normal ECG, and two had no clinical or echographic LV dysfunction. All patients in group 2 had negative AMA scintigraphy and normal T1 scintigraphy. During follow up of 12 AM positive patients, cardiac status improved after immunosuppressive treatment was intensified in nine cases, worsened in two cases, and remained stable in one. During follow up of 24 AM negative patients, cardiac status remained stable in 23 cases despite treatment not being increased in 20, including two patients with sequellary myocardial involvement. The last patient developed mild LV dysfunction after 36 months.

CONCLUSION

AM scintigraphy allows detection of active myocardial damage related to systemic diseases, with increased specificity compared with conventional methods, and increased sensitivity in some cases. Further studies are needed to assess the potential value of AM scintigraphy as a therapeutic guide.

Echocardiography in systemic lupus erythematosus

Two dimensional echocardiography with doppler examination was performed in 54 patients with systemic lupus erythematosus (SLE). Nine (17%) had significant cardiac involvement (four left ventricular hypertrophy, one moderate pericardial effusion, one severe aortic regurgitation, and three ventricular systolic dysfunction). We further studied diastolic function in 45 patients who did not have a major abnormality in echo. SLE was graded as active in 16 patients (SLEDAI > 5) and inactive in 29 patients. Twenty age- and sex-matched subjects acted as controls. The data were compared using one way ANOVA test. Patients with active disease had significant diastolic dysfunction compared to inactive patients and controls as indicated by increased peak A (P < 0.01) and decreased E/A ratio (P < 0.01). There was no linear correlation between disease activity and diastolic dysfunction if SLEDAI was considered as a continuous variable (r=0.29 for E/A). Anticardiolipin antibodies (both IgG and IgM) were elevated in five patients (13 studied). One of them had severe mitral regurgitation, one had trace mitral and aortic regurgitation and one had diastolic dysfunction. We conclude that asymptomatic diastolic dysfunction is present in SLE patients.

Cardiovascular manifestations of systemic autoimmune diseases

The systemic autoimmune diseases are a protean group of illnesses that primarily affect the joints, muscles, and connective tissue. All aspects of the cardiovascular system can be involved with clinical consequences ranging from asymptomatic abnormalities to serious life-threatening conditions. This article discusses the cardiovascular manifestations of the systemic autoimmune diseases with particular focus on clinical pathophysiology and management.

Antiphospholipid antibodies and atherosclerosis

Beta2-Glycoprotein I (beta2-GPI) is a major antigen for anticardiolipin antibodies (aCL) induced in patients with antiphospholipid syndrome and their antigenic epitopes are cryptic. The epitopes appear on the surface of beta2-GPI molecule only when beta2-GPI interacts with lipid membranes containing negatively charged phospholipids or polyoxygenated polystyrene surface. Our data also indicated that CuSO4-oxidized low density lipoproteins (oxLDL) are subsequently targeted by beta2-GPI and aCL; however, malonedialdehyde (MDA)-modified LDL were recognized neither by beta2-GPI nor aCL. Beta2-GPI binding to LDL was rapidly increased by incubation with CuSO4. Oxidation of lipoproteins was accompanied with the increment of thiobarbituric acid-reactive substances (TBARS) and denature of apolipoprotein. Ligands on LDL for beta2-GPI seemed to be intermediate oxidative derivatives which were extractable into the chloroform phase by Bligh and Dyer's extraction, but not MDA. Further, immune responses against beta2-GPI, as an anti-atherogenic protein, were demonstrated to induce atherogenic effect in in vitro oxLDL uptake by macrophages.

Acute myocardial infarction in a young woman with systemic lupus erythematosus

A young woman was diagnosed with systemic lupus erythematosus at the age of 7 years and incurred an acute myocardial infarction at the age of 17 years. Her risk factors for coronary artery disease include hypertension, hypercholesterolemia, a relatively long disease duration, a fairly active disease as evidenced by the history of nephrotic syndrome and other organ system involvement, and a long history of prednisone use. It is difficult to determine the etiology of this patient's acute myocardial infarction without coronary artery histopathology, but aspects of her presentation (a history of virulent systemic lupus erythematosus, and the angiographic findings of ectasia and aneurysm) suggest that coronary arteritis was the etiology of her accelerated coronary artery disease and subsequent myocardial infarction. Acute myocardial infarction is an uncommon occurrence in premenopausal women less than 30 years old.35 These patients are typically found to have an associated systemic disease such as diabetes mellitus or familial hypercholesterolemia. Systemic lupus erythematosus is a less common systemic disease associated with premature coronary artery disease. Mechanisms of acute coronary syndromes in these patients include accelerated atherosclerosis, active coronary vasculitis, and/or vasospasm with superimposed thrombosis.

[Pathology of diseases of extracardiac origin. VI. Disease of the connective tissue and heart]

Connective tissue diseases encompass a wide group of nosologic entities of unknown etiology, characterized by multisystemic organ involvement, sharing an immunologic pathogenetic mechanism, producing a variety of inflammatory manifestations, and whose primary lesion is always a diffuse vasculitis. Any part of the cardiovascular system may be involved, including the pericardium, the myocardium, the endocardium and valves, the coronary arteries, the aorta, the pulmonary vasculature, the peripheral arteries, veins, arterioles, venules, and the capillary beds of almost every organ subsystem. Pathologic studies disclose a high prevalence of heart involvement, but the presence and extent of pathologic findings correlate poorly with clinical manifestations. With the advent of echocardiography-Doppler, milder and earlier cases are now recognized. Although these patients continue under the care of rheumatologists and internists, when cardiac involvement arises, cardiologists must be aware of the characteristics, outcome and management of connective tissue diseases.

Valvular dysfunction in antiphospholipid syndrome: prevalence, clinical features, and treatment

Valvular abnormalities develop in 36% and 35% of patients with primary antiphospholipid syndrome (PAPS) and with systemic lupus erythematosus (SLE) respectively, and in 48% of patients with SLE and antiphospholipid antibodies (aPL). Valvulopathy includes leaflet thickening, vegetations, regurgitation, and stenosis. A literature survey shows that significant morbidity from valvular dysfunction, mostly mitral regurgitation leading to congestive heart failure, occurs in 4% and 6% of SLE and PAPS patients, respectively. The pathogenesis of valvulopathy may involve interaction of aPL with antigens on the valve surface, resulting in valvulitis. Current therapy includes symptomatic measures and valve replacement. A novel approach for symptomatic antiphospholipid syndrome (APS) related valvulopathy involves treatment with systemic corticosteroid. We describe four such patients and their dramatic clinical and hemodynamic response to treatment with prednisone when symptomatic measures failed.

Emergency and critical care issues in pediatric rheumatology

The study of critical care issues in pediatric rheumatology is in its infancy, and the available literature is largely case studies and small retrospective series. A child's limited communication skills and the lack of understanding of disease consequences by both parent and child may cause both overuse and underuse of emergency services. To the extent that small case experiences in children with rheumatic diseases do not adequately reflect possible disease presentations or diagnostic and treatment options, pediatric and adult rheumatologists, intensivists, and emergency physicians should readily turn as needed to larger reported experiences in adults with similar conditions.

Acinetobacter pericarditis with tamponade in a patient with systemic lupus erythematosus

We describe a case of active systemic lupus erythematosus (SLE) complicated with a large amount of pericardial effusion with diastolic collapse of right ventricle suggestive of tamponade. Isolates from surgical drainage of pericardial fluid showed Acinetobacter baumannii exhibiting multiple antibiotics resistance. Despite the high frequency of both pericardial involvement and of infection complications in SLE, septic pericarditis and tamponade is considered rare. Most of the reported cases of septic pericarditis in SLE were due to Staphylococcal aureus, and Acinetobacter baumannii has never been reported before.

Doppler myocardial imaging: a new method of data acquisition for three-dimensional echocardiography

The precise morphologic characteristics of any intracardiac tumor have important implications regarding surgical planning and operative repair. Three-dimensional echocardiography has proved to be a valuable clinical technique in this field. Current methods of three-dimensional reconstruction of two-dimensional images are based on the standard gray-scale imaging technique. However, precordial gray-scale data-set information is frequently of suboptimal quality because of data degradation caused by ultrasound attenuation by chest wall structures. This has limited the use of the transthoracic three-dimensional technique to "echogenic" patients. Doppler myocardial imaging (DMI), a new ultrasound technique based on the Doppler principle, is influenced less by chest wall attenuation and in addition offers a better boundary detection algorithm for the cardiac structures. To determine if there may be a potential benefit of DMI to acquire data for three-dimensional reconstruction, a 33-year-old woman with a large intracardiac mass was studied. In this case three-dimensional gray-scale and DMI data sets were compared and contrasted with pathologic information. DMI allowed both the qualification of mass volume and the correct definition of the morphology of the mass. It was also possible to identify the precise site of attachment of the mass to the mitral valve leaflets. The information thus obtained was correlated with both operative and pathologic findings.

Acute myocarditis and left ventricular aneurysm as presentations of systemic lupus erythematosus

A case of systemic lupus erythematosus (SLE) associated with fever, heart failure, and left ventricular (LV) aneurysm is reported. A diagnosis of SLE was suspected owing to the presence of active lymphocytic myocarditis and fibrinous endocarditis at LV endomyocardial biopsy and was confirmed by identification of 4 of the 11 criteria proposed by the American Rheumatism Association for the definition of SLE. A 2-month period of steroid therapy was followed by a remarkable recovery of LV function and progression of endomyocarditis to a healed phase at control LV biopsy. The LV aneurysm disappeared, likely because thrombosis occurred as a result of the hypercoagulable state accompanying the presence of anticardiolipin antibodies. This is the first reported case of LV aneurysm induced by SLE and is a rare clinicohistologic documentation of the effectiveness of steroid treatment on lupus endomyocarditis.

Dissecting aortic aneurysm in systemic lupus erythematosus

Many cardiovascular manifestations have been described in systemic lupus erythematosus (SLE). Aortic involvement, however, is very rare. We describe a 30-year-old woman with SLE who presented with extensive aortic dissection, and review the few reported cases. We discuss possible pathogenic mechanisms for aortic involvement in lupus and the appropriate diagnostic work-up.

Sports Injury Look-Alikes

In brief Sports medicine physicians see brief overuse, chronic, or recurrent injuries in athletes every day. However, some patients who have symptoms consistent with these injuries actually have underlying disease. Three case studies examine athletes who initially seemed to have overuse syndromes or recurrent chronic injuries. The eventual diagnoses were rheumatoid arthritis, systemic lupus erythematosus, and gout.

The arteritides

This article reviews the histopathological, clinical and immunological features of the arteritides. Based on these criteria, a classification scheme is proposed that includes infectious and non-infectious causes. Included in the non-infectious arteritides are: hypersensitivity vasculitis including serum sickness. Henoch-Schönlein purpura, mixed cryoglobulinaemia, hypocomplementaemia, drug and malignancy-associated vasculitis; arteritides of small and medium-sized arteries including polyarteritis nodosa, Kawasaki's disease, Wegener's granulomatosis, Churg-Strauss syndrome, necrotizing sarcoid granulomatosis, thromboangiitis obliterans (Buerger's disease) and localized forms of arteritis; arteritides involving large, medium and small-sized arteries which includes giant cell (temporal) arteritis, Takayasu's disease and arteritis of collagen-vascular disease (rheumatoid arthritis, rheumatic fever, Behçet's disease, Sjörgren's syndrome, systemic lupus erythematosis and systemic sclerosis.

Coronary artery bypass in systemic lupus erythematosus using total autogenous arterial bypass

A 63-year-old man with systemic lupus erythematosus (SLE) underwent coronary artery bypass grafting using only arterial grafts, the left internal thoracic, and the right gastroepiploic arteries. This is the first report of coronary artery bypass grafting in a patient with SLE using the gastroepiploic artery.

Exercise capacity and hemodynamics in systemic lupus erythematosus: a Doppler echocardiographic exercise study

Although pulmonary hypertension is a well-described manifestation of systemic lupus erythematosus, there are few data regarding the pulmonary artery pressure response to exercise. We hypothesized that exercise capacity was reduced and that the pulmonary artery pressure response to exercise was abnormal in patients with systemic lupus erythematosus. To test these hypotheses, we performed Doppler exercise echocardiography in 18 patients with lupus and 10 normal control subjects. Exercise duration was significantly reduced in the patients with lupus (8.1 vs 14.4 minutes for control subjects, p < or = 0.001). Pulmonary artery pressure was significantly higher in the patients with lupus at rest and during the first two stages of exercise (p < 0.05). Cardiac indexes at rest were similar in the two groups, suggesting that increased pulmonary vascular resistance was the mechanism for the higher pulmonary pressure we observed. We conclude that abnormal exercise hemodynamics may contribute to reduced exercise capacity in patients with lupus.

The left ventricle in systemic lupus erythematosus: initial observations and a five-year follow-up in a university medical center population

The objectives of this study were to determine the natural history of abnormalities in left ventricular size and function in patients with systemic lupus erythematosus and to determine whether changes in ventricular function can be attributed to a primary lupus cardiomyopathy. The design was a prospective 5-year follow-up study in a university hospital. There were 28 patients with systemic lupus erythematosis who were enrolled in an echocardiographic study from 1985 to 1986 and who were available for follow-up echocardiographic examinations. Patients were prospectively subgrouped according to the presence or absence of systemic hypertension. Twenty healthy volunteers participated as normal control subjects. Measurements of left ventricular mass index, mean wall thickness, volumes, and ejection fraction and Doppler indices of mitral inflow were performed on all patients and control subjects. Increases in left ventricular mass index, mean wall thickness, and end-systolic volume and decreases in ejection fraction were seen in the patients with lupus when compared with control subjects (p < or = 0.05) and were related to the presence of hypertension and coronary artery disease. In the group of patients without hypertension, no significant differences in left ventricular mass index, volumes, or ejection fraction were detected when compared with the control group. The normotensive patients did demonstrate mild abnormalities of mitral inflow that did not worsen during the follow-up period. It was concluded that abnormalities of systolic and diastolic left ventricular function are common in patients with lupus, are progressive over time, and are related to the coexistence of hypertension and coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

A comparison of cardiac valvular involvement in the primary antiphospholipid syndrome versus anticardiolipin-negative systemic lupus erythematosus

Recurrent thrombosis and pregnancy loss are well-recognized features of the antiphospholipid syndrome. Uncertainty exists, however, as to whether other reported features of the antiphospholipid syndrome such as cardiac valvular vegetations are truly part of this disorder or more reflective of associated systemic lupus erythematosus (SLE). Several recent studies have concluded that patients with antiphospholipid antibodies have a higher risk of developing Libman-Sacks endocarditis. This study was performed to determine whether antiphospholipid antibodies are the only risk factors for cardiac valvular disease in patients with primary antiphospholipid syndrome (PAPS) or SLE. Ten patients with PAPS were matched with 20 patients with SLE and 20 healthy control subjects by sex. All participants were tested for anticardiolipin (aCL) antibodies by means of a standardized enzyme-linked immunosorbent assay technique, and all underwent two-dimensional and color-flow Doppler echocardiography. The echocardiograms were interpreted by two cardiologists blinded to the patients' underlying disease. Sixty percent of the PAPS group had cardiac valvular involvement compared with 40% of the SLE group (p = NS). We conclude that cardiac valvular vegetations are common both in aCL-negative patients with SLE and in patients with PAPS. This suggests that aCL antibodies either play no causative role or are not the only risk factors in the development of cardiac valvular vegetations.

Left ventricular aneurysm, normal coronary arteries and embolization in a patient with systemic lupus erythematosus

We describe a 30-year-old woman with a normal appearing coronary artery associated with SLE who suffered myocardial infarction with left ventricular aneurysm and systemic embolization including cerebral infarctions and saddle embolism. The patient was surgically treated with good results. To our knowledge this is the first reported case of systemic embolism due to myocardial infarction occurring in SLE with a normal coronary artery.

Systemic lupus erythematosus valve disease by transesophageal echocardiography and the role of antiphospholipid antibodies

OBJECTIVES

The aims of this study were to better characterize valve disease in systemic lupus erythematosus and to determine its association with antiphospholipid antibodies.

BACKGROUND

Estimates of the prevalence of valve disease in systemic lupus erythematosus have been higher in autopsy series than in clinical studies using transthoracic echocardiography. Antiphospholipid antibodies have been suggested to be a primary pathogenetic factor.

METHODS

Transesophageal echocardiography was performed on 1) 54 patients with lupus erythematosus, 22 of them with (group I) and 32 without (group II) antiphospholipid antibody; 2) on 10 patients with antiphospholipid syndrome (group III); and 3) on 35 normal subjects (group IV).

RESULTS

Patients in groups I and III had similar types and concentrations of antibodies. Leaflet thickening was found in 50% of group I, 47% of group II, 10% of group III and 9% of group IV patients (group I or II vs. group III or IV, p < 0.03). Leaflet thickening in patients with lupus erythematosus was diffuse; it usually involved the mitral and aortic valves and was associated with valve regurgitation (73%) or valve masses (50%). Valve masses were observed in 41% of group I, 25% of group II, 10% of group III and in none of group IV patients (group I or II vs. group IV, p < 0.002). Most valve masses in patients with lupus erythematosus were located near the base on the atrial side of the mitral valve or on the vessel side of the aortic valve, had variable size (0.2 to 0.85 cm2), shape and echodensity. Valve regurgitation was observed in 64% of group I, 59% of group II, 10% of group III and 20% of group IV patients (group I or II vs. group III or IV, p < 0.006). Moderate or severe regurgitant lesions were noted in 27% of group I and 25% of group II patients.

CONCLUSIONS

Lupus erythematosus valve disease is frequent (74%) regardless of the presence or absence of antiphospholipid antibodies. Therefore antiphospholipid antibodies may not be a primary pathogenetic factor. The characteristic appearance of leaflet thickening and masses in patients with lupus erythematosus may be unique.

Detecting cardiac valvular pathology in patients with systemic lupus erythematosus

Systemic lupus erythematosus (SLE) is associated with multiple cardiac complications, including valvular damage and an increased risk of bacterial endocarditis. The purpose of this study was to evaluate prospectively a group of patients with SLE for the presence of valvular abnormalities in order to assess their candidacy for antibiotic prophylaxis prior to invasive dental procedures. Of the 43 participants, 19 (44%) had echocardiographic evidence of valvular pathology; however, only seven (16%) had a physical exam consistent with pathologic valve anatomy or function. Because of the high percentage of SLE patients with valvular abnormalities, and the poor sensitivity of the physical exam, referral to a cardiologist for echocardiography is suggested prior to invasive dental care for patients with SLE. If cardiac valvular pathology is detected, antibiotic prophylaxis should be considered.

[Circulating lupus coagulation inhibitor in two sisters, one with disseminated lupus erythematosus and the other with immunologic thrombocytopenic purpura]

Familial cases of lupus anticoagulant were rarely described. We report the observation of two sisters with lupus anticoagulant, one with thrombocytopenic purpura and the other with systemic lupus erythematosus.

Impairment of left ventricular diastolic function in systemic lupus erythematosus

Left ventricular (LV) diastolic performance was evaluated with pulsed-wave Doppler echocardiography in a cross-sectional population of patients with systemic lupus erythematosus (SLE) in search of subclinical myocardial involvement. Such involvement is reported to occur infrequently, despite pathohistologic evidence of myocarditis in up to 70% of patients with SLE. Thirty-five consecutive patients with SLE were evaluated, 14 with active and 21 with inactive disease, and were compared with 30 age-matched healthy control subjects. Twenty-six patients were restudied at 7 months. All had normal LV systolic function, normal pericardial and valvular structures, and no significant valvular regurgitation on Doppler echocardiography. In SLE patients with active disease, indexes of LV diastolic function differed significantly from the inactive group and from control subjects, with marked prolongation of isovolumic relaxation time (104 +/- 18 vs 74 +/- 13 ms, p = 0.0001), as well as reduced peak early diastolic filling velocity (E) (0.69 +/- 0.19 vs 0.83 +/- 0.17 ms, p = 0.01), reduced ratio of early to late diastolic flow velocity (E/A) (1.15 +/- 0.53 vs 1.47 +/- 0.35, p = 0.02), and prolonged mitral pressure halftime (74 +/- 14 vs 65 +/- 8 ms p = 0.01). Similar significant differences were found between the active and inactive SLE patient groups. SLE patients with inactive disease differed from control subjects in only mild prolongation of mitral pressure halftime. Abnormal prolongation of isovolumic relaxation (greater than 100 ms) was found to be the most useful marker of diastolic impairment, being present in 64% of SLE patients with active disease and in 14% of patients with inactive disease.(ABSTRACT TRUNCATED AT 250 WORDS)

The atherogenic effect of lupus sera: systemic lupus erythematosus-derived immune complexes stimulate the accumulation of cholesterol in cultured smooth muscle cells from human aorta

The influence of systemic lupus erythematosus (SLE) patients' sera on lipid accumulation in the cultured smooth muscle cells (SMC) from unaffected human aortic intima was examined. It was demonstrated that the cholesterol uptake in the SMC cultured in the presence of SLE sera is 1.5- to 6-fold higher than in the cells cultured with normal human sera (NHS) obtained from healthy donors. Incubation of the SMC with circulating immune complexes (CIC) isolated from lupus sera by precipitation with 2.5% polyethylene glycol 6000 (PEG) caused a 3- to 4-fold rise in the intracellular cholesterol level. The atherogenic effect of lupus sera, as well as isolated CIC, strongly correlated (r = 0.98) with the low density lipoprotein (LDL) content in the PEG-precipitated CIC. The cholesterol level in cultured SMC also increased 2- to 3-fold when growth medium was supplemented with LDL, DNA, and anti-DNA autoantibodies (IgG) affinity isolated from lupus sera. Using immunofluorescent staining, it was shown that the addition of a DNA-anti-DNA IgG mixture to the growth medium, together with NHS, stimulated LDL incorporation in the SMC. The results of double-label staining suggest the formation of LDL-DNA-IgG complexes which seem to be entrapped in cells more actively than free LDL. The composition of PEG-precipitated CIC was studied by electrophoresis and immunoblotting. Significant amounts of apolipoprotein B, as well as low molecular weight DNA and immunoglobulins, were found in SLE-derived CIC. The data obtained suggest that the atherogenic effect of human lupus sera in vitro is generally due to the appearance of LDL-containing immune complexes. Different mechanisms possibly involved in the lupus atherogenesis are discussed.

Myocardial systolic function in systemic lupus erythematosus: a study based on radionuclide ventriculography

We assessed left ventricular systolic function by means of radionuclide ventriculography in 20 consecutive unselected patients with systemic lupus erythematosus. All patients had normal left ventricular systolic function (defined as ejection fraction greater than 45%) in a resting state. Regional wall motion abnormalities were, however, seen in 4 patients (20%). Of these 20 patients, 8 were able to exercise on a bicycle ergometer. These patients were subjected to exercise radionuclide ventriculography. Of these 8 patients, 3 (37.5%) had an abnormal ventriculographic response to exercise (as evidenced by a subnormal rise in ejection fraction or a fall, appearance of a new regional wall motion abnormality or worsening of a pre-existing one). This probably reflects subclinical left ventricular dysfunction unmasked by the stress of exercise. The clinical significance of these abnormalities on long-term myocardial function and their possible reversibility with remission of the disease needs to be assessed in future studies.

Cardiac disease in systemic lupus erythematosus: prospective study of 70 patients

A prospective two dimensional and Doppler echocardiographic study of 70 consecutive patients with systemic lupus erythematosus (SLE) and 40 controls was carried out. Forty patients (57%) were found to have echocardiographic disturbance. Valvular abnormalities were detected in 31 patients (44%) and in only two controls (5%). Mitral valve abnormalities were the most common findings (23/70 (33%)) with mild or moderate regurgitation the most frequent lesion (16% and 9% respectively). Three patients (4%) had a morphological echocardiographic pattern suggestive of non-infective verrucous vegetations affecting the mitral valve. No patient had haemodynamically significant clinical valve disease. Pericardial effusion was identified in 19 patients (27%), of whom 14 had mild and clinically silent disease. Myocardial abnormalities were found in 14 patients (20%), but clinical features of myocardial dysfunction were present in only one. Patients with antiphospholipid antibodies were found to have an increased prevalence of endocardial lesions, mainly valvular regurgitation. It is concluded that the inclusion of echocardiography in a study protocol of patients with SLE can identify an important subset of patients with cardiac abnormalities, many of which are clinically silent. In addition, the association of antiphospholipid antibodies with endocardial lesions suggests that these antibodies may have a prominent role in the pathogenetic mechanisms of heart valve disease in SLE.

Cardiac tamponade as an initial manifestation of systemic lupus erythematosus in early childhood

Cardiac tamponade is rare as an initial manifestation of systemic lupus erythematosus (SLE), and even more so in paediatric patients. This paper reports an 8 year old girl with SLE with several unusual features: unusual age of presentation, unusual initial organ manifestation and recurrent cardiac tamponade as a complication.

Systemic lupus erythematosus complicated by tricuspid stenosis and regurgitation: successful treatment by valve transplantation

Clinical tricuspid stenosis has not previously been reported in patients with systemic lupus erythematosus (SLE). A 25 year old woman with active SLE presented with signs of severe right ventricular failure. Cardiac catheterisation confirmed the diagnosis of tricuspid stenosis and regurgitation together with mitral regurgitation. This patient underwent successful tricuspid and mitral valve replacement.

Myocardial infarction due to intracoronary thrombi without significant coronary artery disease in systemic lupus erythematosus

Acute myocardial infarction is a potentially fatal complication of SLE. Reported mechanisms include atherosclerosis, arteritis and coronary arterial spasm. The following case report presents a fourth possible cause; intracoronary thrombus with angiographically normal coronary arteries in a patient with active lupus and AMI.